Noombah
Deceased
Trevor King (Noombah)
Demographics
39y, male
Date of death
2018-02-10
Finding date
2022-01-11
Cause of death
Cardiac arrest in a person with pre-existing severe ischaemic heart disease who was restrained and had consumed volatile hydrocarbons
AI-generated summary
A 39-year-old First Nations man with severe ischaemic heart disease died following police restraint and ambulance care during an emergency examination authority detention. He had sniffed petrol and threatened self-harm; police located him and detained him. During restraint, a potential lateral vascular neck restraint was applied. Paramedics failed to perform vital signs assessment or cardiac monitoring at the scene despite information about his cardiac history and obvious clinical decline from agitation to unresponsiveness. Cardiac arrest was identified only after he was loaded in the ambulance. Critical clinical lessons: (1) recognize rapid decline from agitation to unresponsiveness as a medical emergency requiring priority assessment; (2) paramedics must conduct immediate vital signs and cardiac monitoring at scenes involving restraint, especially with cardiac risk factors; (3) role confusion between police and paramedics regarding clinical responsibility should be clarified; (4) better culturally appropriate mental health response systems are needed for First Nations people.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- severe coronary artery atherosclerosis (75% narrowing LAD, >90% narrowing RCA)
- past myocardial scarring
- prior stent insertion
- petrol inhalation (volatile hydrocarbons)
- cannabis consumption
- physical restraint by police
- failure to perform cardiac assessment at scene
- failure to identify critical clinical decline from agitation to unresponsiveness
- delay in cardiac monitoring (8+ minutes)
- suboptimal cardiopulmonary resuscitation
Coroner's recommendations
- Queensland Police Service include in the Operational Procedures Manual a mandatory requirement for police officers to request a priority response from the Queensland Ambulance Service, requiring a medical assessment and monitoring of vital signs, when officers observe a person in custody whose demeanour rapidly declines from a state of heightened emotion and agitation to one of apparent compliance
- Queensland Police Service review the inclusion and training of Lateral Vascular Neck Restraint in the situational use of force model
- Queensland Government work with First Nations peoples in Townsville, the Northern Queensland Primary Health Network and an organisation such as Thirrili to develop culturally appropriate referral pathways for First Nations people in mental health crisis as an alternative to assessment in hospital emergency departments
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